If a procedure or safety rule was not followed, why was the procedure or rule not followed?.
When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. In conducting an incident investigation, the team must look beyond the immediate causes of an incident. Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each bring different knowledge, understanding and perspectives to the investigation. Incident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also improve workplace morale and increase productivity, by demonstrating an employer's commitment to a safe and healthful workplace. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents. Investigating a worksite incident- a fatality, injury, illness, or close call- provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA suggests using the term "incident" investigation. To many, "accident" suggests an event that was random, and could not have been prevented. In the past, the term "accident" was often used when referring to an unplanned, unwanted event. OSHA strongly encourages employers to investigate all incidents in which a worker was hurt, as well as close calls (sometimes called "near misses"), in which a worker might have been hurt if the circumstances had been slightly different.
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